NDIS Physiotherapy Initial Assessment

Section: Patient Information

• Name: Liam Connor
• Date of Birth: 14/05/1988
• NDIS Number: 430892115
• Address: 42 Stirling Highway, Nedlands WA 6009
• Contact Information: 0412 345 678, l.connor88@email.com.au

Emergency contact is his wife, Sarah Connor (0412 345 679), who resides at the same address and acts as his primary informal carer.

Employed part-time (15 hrs/week) as a remote data analyst. Assists with light household admin and meal planning at home.

Current NDIS plan dates: 01/02/2026 to 31/01/2027. Plan-managed funding (Capacity Building - Improved Daily Living, and Capital Supports). NDIS goals include maintaining safe independent mobility within the home and community, and sustaining part-time employment.

Section: Primary Diagnosis / Disability

Secondary Progressive Multiple Sclerosis (SPMS) characterised by asymmetrical lower limb paraparesis (R > L), spasticity, and neurogenic fatigue.

Secondary diagnoses include neurogenic bladder, mild depression, and osteopenia.

Initially diagnosed with Relapsing-Remitting MS (RRMS) on 12/08/2014 by Dr Alan Grant (Neurologist) at Sir Charles Gairdner Hospital; transitioned to SPMS in November 2023.

Section: Medical History

• Secondary Progressive Multiple Sclerosis (SPMS)

• Detrusor hyperreflexia (neurogenic bladder)

• Mild clinical depression

• Lower limb osteopenia (DEXA scan 2024)

• Right ankle ORIF following mechanical fall (10/03/2019)

• baclofen (Lioresal®) 10 mg PO TID

• ocrelizumab (Ocrevus®) 600 mg IV 6-monthly

• oxybutynin (Ditropan®) 5 mg PO BID

• escitalopram (Lexapro®) 10 mg PO daily

• colecalciferol (OsteVit-D®) 25 mcg (1,000 IU) PO daily

• Penicillin (anaphylaxis)

Section: Social / Environmental History

Lives in a single-storey, private rental brick home with his wife.

Supported primarily by his wife, Sarah, who works full-time. Formal NDIS support workers attend for 2 hrs, 3x/week to assist with heavy domestic tasks, meal preparation, and community access.

English is the primary language spoken at home. No specific cultural barriers identified.

Wakes at 07:30, completes self-care seated, works from home 09:00 to 12:00, rests in the afternoon due to fatigue, and engages in seated hobbies (gaming, reading) in the evening.

Section: Mobility and Function

Ambulates indoors using a 4-wheeled walker (4WW) and a right ankle-foot orthosis (AFO). Mobilises outdoors using a manual wheelchair propelled by his wife or a folding power wheelchair for independent community access.

• Bed mobility: Independent with use of a bed pole.
• Sit-to-stand: Independent from raised surfaces using UL push; requires 1x standby assistance from low or soft surfaces when fatigued.
• Toilet transfers: Independent using bilateral grab rails and raised toilet seat.
• Car transfers: Requires 1x minimal physical assistance to lift R LL into the vehicle.

Unable to negotiate stairs safely; avoids stairs in the community and uses ramps exclusively.

Walks a maximum of 30 m indoors before onset of right foot drop exacerbation and significant trunk sway, requiring a 10-minute seated rest.

History of 3 mechanical falls in the past 6 months indoors, all occurring in the late afternoon due to R toe catch on carpet transitions when fatigued. No fractures sustained.

Static sitting balance is independent. Static standing balance requires UL support. Dynamic standing balance is impaired with reduced limits of stability posteriorly and to the right.

Left UL is functionally intact (dominant side). Right UL demonstrates mild intention tremor and reduced fine motor coordination, limiting prolonged typing and carrying hot liquids while mobilising.

Section: Communication and Cognition

Alert, oriented, and demonstrates intact comprehension. Follows complex multi-step instructions without difficulty.

Experiences Uhthoff's phenomenon (heat sensitivity) resulting in rapid cognitive and physical fatigue if ambient temperature exceeds 25 °C; requires air-conditioned environments for therapy.

Communicates verbally without difficulty; no AAC required.

Section: Pain

Reports chronic dull ache in the low back (NRS 4/10) after prolonged sitting (> 2 hours) and intermittent cramping pain in the right calf (NRS 6/10) overnight secondary to spasms. Managed with oral baclofen, positional changes, and heat packs to the lumbar spine.

Section: Equipment

• Carbon fibre right AFO (off-the-shelf)
• Seat walker (4WW)
• Pride Mobility folding power wheelchair
• Over-toilet frame and shower chair
• Bed stick

The 4WW, bathroom equipment, and power wheelchair remain suitable and in good repair. The current R AFO shows signs of wear at the strapping and provides insufficient dorsiflexion assist during peak fatigue.

Previously trialled a single-point stick in 2022, which was rejected due to inadequate mediolateral stability and high falls risk.

Section: Home Environment and Accessibility

The home features a 4 cm step at the front entrance (currently managed with a portable rubber threshold ramp) and plush carpet in the bedrooms which increases resistance for the 4WW. Narrow hallway (85 cm width) restricts turning circle for the power wheelchair indoors.

Grab rails were installed in the bathroom and toilet in 2024. Future needs include removal of bedroom carpet or transition to low-pile flooring, and a permanent concrete wedge ramp at the front entry.

Section: Support Team and Allied Health Involvement

• Occupational Therapist: Emma Watson (Ability Allied Health)

• Continence Nurse: Jane Doe (MS WA)

• Neurologist: Dr Alan Grant (SCGH)

• General Practitioner: Dr Samira Patel (Nedlands Medical Centre)

• Support Coordinator: Mark Evans (Connect NDIS Services)

Section: Subjective

Referred by Support Coordinator for an initial physiotherapy assessment to address recent indoor falls, progressive decline in walking endurance, and to establish an ongoing maintenance therapy plan for NDIS review.

Both Liam and Sarah demonstrate a strong understanding of SPMS and the progressive nature of his neurological deficits, recognising the need for energy conservation and proactive falls prevention.

Primary concerns include tripping over the right foot in the evenings, difficulty transferring out of his office chair after work, and fear of falling when home alone while his wife is at work.

Previously attended outpatient neuro-rehabilitation at SCGH in 2023 (6-week block) with good effect on balance, and received sporadic private physiotherapy in 2025, which ceased due to funding exhaustion.

Hopes to reduce indoor falls to zero, improve R leg clearance, and maintain the physical capacity to transfer independently so he does not require daytime carer support while his wife works.

Section: Patient-Centered Goals

• Reduce indoor falls from 3 per 6 months to 0 over the next 12 weeks by implementing a fatigue management plan and trialling a functional electrical stimulation (FES) device.

• Increase indoor 4WW ambulation endurance from 30 m to 60 m without toe drag within 12 weeks.

• Maintain independent sit-to-stand transfers from all home surfaces over the next 12 months to preserve autonomy during the day.

• Sustain current baseline lower limb strength and range of motion over the next 12 months to delay full-time indoor wheelchair dependence.

• "I want to be able to move around my house safely and independently."

• "I want to maintain my physical wellbeing to continue working part-time."

Section: Objective Assessment

• Posture: Seated posture shows mild thoracic kyphosis and posterior pelvic tilt.

• Gait: Ambulates with 4WW and R AFO. Decreased step length bilaterally, absent R heel strike, R hip circumduction during swing phase, and genu recurvatum on R stance phase.

• Skin integrity: Intact; mild blanchable erythema noted over R navicular from AFO strap.

• Bilateral hip extension: -5 degrees (Thomas test positive for iliopsoas tightness).

• Right ankle dorsiflexion (knee extended): -5 degrees (passive), -15 degrees (active).

• Right ankle dorsiflexion (knee flexed): 0 degrees (passive).

• Left ankle range of motion: WNL.

• Right LL (MMT): Hip flexion 3-/5, Hip abduction 3-/5, Knee extension 4-/5, Knee flexion 3/5, Ankle DF 1/5, Ankle PF 3/5.

• Left LL (MMT): Hip flexion 4/5, Hip abduction 4/5, Knee extension 4+/5, Knee flexion 4/5, Ankle DF 4/5, Ankle PF 4+/5.

• Bilateral UL: 5/5 throughout, except R grip strength slightly reduced compared to L.

• Static sitting: Independent, stable.

• Static standing (unsupported, eyes open): 15 seconds with significant postural sway.

• Static standing (unsupported, eyes closed): Unable to maintain (positive Romberg).

• Dynamic standing: Berg Balance Scale (BBS) score = 34/56 (indicates increased risk of falls).

• Timed Up and Go (TUG) with 4WW: 24.5 seconds (high falls risk).

• 10-Metre Walk Test (10MWT) with 4WW: 0.35 m/s (household ambulator classification).

• 5 Times Sit to Stand (5xSTS): 22.0 seconds (requires UL push on armrests).

• Tone/Spasticity: Modified Ashworth Scale (MAS) = 2 in R gastrocnemius/soleus, MAS = 1+ in R hamstrings.

• Reflexes: Hyperreflexia (3+) at R patellar and Achilles tendons; positive R Babinski sign; clonus present at R ankle (4 beats).

• Coordination: Mild dysmetria on R finger-to-nose and R heel-to-shin testing.

Baseline resting HR 72 bpm, BP 122/78 mmHg. Following mobility testing (approx. 15 mins of intermittent exertion), patient reported RPE of 7/10 (Modified Borg Scale) with visible increase in R foot drop and trunk sway. Recovered to baseline RPE 2/10 after 10 mins seated rest in air-conditioned room (21 °C).

Section: Assessment / Clinical Impression

37-year-old male with SPMS presenting with asymmetrical spastic paraparesis (R > L), R ankle plantarflexor contracture/spasticity, and significant neurogenic fatigue. Key functional limitations include reduced indoor gait velocity, impaired dynamic balance, and high falls risk secondary to R foot drop. Strengths include intact cognition, strong UL strength for transfers, supportive home environment, and high motivation to engage in therapy.

SPMS with right-sided predominance; Expanded Disability Status Scale (EDSS) estimated at 6.0 (requires unilateral/bilateral constant assistance to walk ~100 m without rest).

Impairments directly restrict his ability to safely navigate his home environment during the afternoon/evening, threaten his independence while his wife is at work, and limit community participation without wheeled mobility.

High risk of indoor mechanical falls (particularly when fatigued or exposed to heat), risk of R ankle contracture progression, and risk of secondary deconditioning.

Section: Plan

• Spasticity management and prolonged stretching for R plantarflexors and bilateral hip flexors.
• Progressive resistance training targeting L LL and proximal R LL (gluteals, quadriceps).
• Task-specific transfer training (office chair and low surfaces) and dynamic balance retraining.
• Gait re-education and orthotic/FES review to improve R swing phase clearance.

Fortnightly 60-minute home-based physiotherapy sessions for 24 weeks (total 12 hours), followed by a formal progress review and outcome measure reassessment.

Trial of a Functional Electrical Stimulation (FES) foot drop device (e.g., Bioness L300 Go or WalkAide) in clinic, and referral to an Orthotist to review and replace the worn carbon fibre R AFO.

Liaise with OT (Emma Watson) regarding office chair modifications/cushion raise to assist sit-to-stand transfers, and provide a joint therapy report to Support Coordinator (Mark Evans) 6 weeks prior to NDIS plan reassessment.

• Pacing and energy conservation strategies (managing neurogenic fatigue and Uhthoff's phenomenon).
• Safe falling techniques and floor-to-chair transfer training for both patient and wife.
• Daily skin checks around R ankle bony prominences post-AFO use.

Initiate a tailored seated and supine HEP (3x/week on non-therapy days) focusing on R calf stretching, supine bridges, and seated knee extensions. Recorded on Physitrack app with video demonstrations; to be reviewed and progressed fortnightly.

• Orthotist (for custom AFO review).
• Rehabilitation Physician / Neurologist (to review baclofen dosage or consider focal Botulinum Toxin-A injections for R gastrocnemius spasticity).